Copy of own record / clearance letter request form

Oregon State Police

Copy of Own Record / Clearance Letter Request

COPY OF OWN RECORD / CLEARANCE LETTER REQUEST FORM | Revised 2022-12

The Oregon Copy of Own Record/Clearance Letter is the result of a fingerprint-based background check.

Complete the following steps to obtain a copy of your own Oregon Criminal History report or Clearance Letter

indicating that you have no Oregon Criminal History:

1. Obtain properly rolled set of your fingerprints using the blue applicant fingerprint card (FD258).

An example of this fingerprint card is available at:

https://www.edo.cjis.gov/artifacts/standard-fingerprint-form-fd-258-1.pdf

To hel

p avoid rejection or delays, please ensure the 6 required fields on the fingerprint card are complete.

Your printed name, your signature, date of birth, gender, race, and the Fingerprint Agencies signature

are required fields. *** Your fingerprint card will be returned with your response. ***

2. S

ubmit your completed request form along with your fingerprint card and payment to OSP. If submitting

by mail, send your completed form, fingerprint card and check or money order to:

Oregon State Police -- CJIS Division

Unit 11

P.O. Box 4395

Portland, OR 97208-4395

ue to the confidentiality of the criminal history information, results will only be mailed to the subject of

the Copy of Own Records request. OSP will not send results to attorneys, employers, schools, etc.

ngerprinting Services:

The Oregon State Police offers public fingerprinting services at our Salem General Headquarters. This is a walk-

in only service available Monday-Friday 8am to 4:30pm, excluding holidays. Valid government issued photo

identification is required. We accept checks, money orders, cash and all major credit cards except American

Express. Checks and money orders must be made payable to Oregon State Police.

OSP General Headquarters are located at:

3565 Trelstad Ave SE

Salem, OR 97317

Fees:

For

more information or questions, please contact the COR/Open Records unit.

Phone: 503-934-2307

Email: Open.records@osp.oregon.gov

Service Type

Fee

Copy of Own Record/Clearance Letter

$33

Public Fingerprinting

$30

Notary Service for Copy of Own Record

$5 per copy

Oregon State Police

Copy of Own Record / Clearance Letter Request

COPY OF OWN RECORD / CLEARANCE LETTER REQUEST FORM | Revised 2022-12

This form is to be used to request a copy of your own Oregon Criminal History or Clearance Letter information.

This is an Oregon only request and the results will only include information for Oregon. This record is based on

your fingerprints provided. The results will only be mailed to the subject of the “Copy of Own Record” request.

This form may be copied.

Subject: __________________________ ______________________ _______________________ ______

Last name First name Middle name Suffix

ther Names Used: ________________________________________________________________________

ate of Birth: ______________________________ Social Security Number: _____________________

Mailing Address: _________________________________________________________________________

Cit

y: _____________________ State: __________________ Zip Code: ___________ Country: ____________

Tel

ephone: ______________________ Email Address: ___________________________________________

****Email is required if mailing out of the United States; We do not make calls outside the US.****

would like to pick up my results at OSP General Headquarters (ID required) ☐

Payment Information:

$33.

00 Check/Money Order included ☐

$5.00 Notarized Response Requested ☐

Note: Checks and money orders must be made payable to Oregon State Police.

otal Included $____________

__________________________________________

_______ _____________

Signature Date